Objective: Advanced oral cancers are a challenge for treatment, as they require complex procedures for excision and reconstruction. Despite being occurring at a visible site and can be detected easily, many patients present in advanced stages with large tumors. Timely intervention is important in improving survival and quality of life in these patients. The aim of the present study was to find out the causes of delay in seeking specialist care in advanced oral cancer patients. Materials and Methods: A prospective questionnaire based study was done on 201 consecutive advanced oral squamous cancer patients who underwent surgery at our hospital. All patients had either cancer of gingivobuccal complex (GBC) or tongue and had tumors of size more than 4 cm (T3/T4) and were treatment naοve at presentation. RESULTS: Even though most patients observed abnormal lesions in their mouth, majority delayed the decision to visit a physician early. A significant percentage of patients (50%) also reported a delayed diagnosis by the primary care physician before being referred to a tertiary care center for definitive treatment. The average total duration from symptoms to treatment was 7 months. Conclusion: The main reasons of this delay in receiving treatment were due to patients themselves (primary delay) or due to time taken by the primary physician to diagnose the condition (secondary delay). Oral self-examination can be helpful in detecting oral cancers early.

Squamous cell carcinoma of the oral cavity (OSCC) represents a dominant portion of cancer burden in India. Developments in the field of evaluation and treatment in the last decade have resulted only in a modest improvement in survival rate due to the high incidence of second primary and recurrence. [1] Morbidities associated with OSCC and current treatment modalities are significant and include eating and swallowing difficulties. occur at a visible site and can be detected easily, many patients present in advanced stages with large tumors. Advanced oral cancers are a challenge for treatment, as they require complex procedures for excision and reconstruction. [2] Moreover they affect the quality of life and survival significantly. prevention of these tumors may not be possible always, early detection and treatment is possible with adequate awareness among clinicians and patients. Screening for oral cancer is useful to detect cancers in their early stage and can decrease mortality in high-risk populations. [3],[4] Timely intervention is therefore equally important in improving survival and quality of life in patients with oral cancers. In this prospective questionnaire-based study, we tried to understand the underlying reasons for delay in seeking specialist care by patients with oral cancers.

» Materials and Methods

A prospective questionnaire-based study was done on 201 consecutive advanced oral squamous cancer patients who underwent surgery at a tertiary care center during 2011-2012. All patients had cancer either of the gingivobuccal complex (GBC) or tongue and had tumors of size more than 4 cm (T3/T4) and were treatment-naïve at presentation. Apart from detailed history of illness, specific questions about educational status, access to medical care, and other reasons for the delay in seeking specialist care were elicited from these patients. A surgery registrar interviewed all these patients during evaluation for surgery.

» Results

The mean age of these patients was 48 years with a male-to-female ratio of 6:1 [Table 1]. 20% had no formal education, most had at least a primary education. The mean distance to the nearest primary care center was 10 km and only 14% had insurance cover.

Tobacco usage was common among all these patients. About 79% were tobacco chewers and 27% were smokers. Thirty-one percent used alcohol regularly or occasionally. only 8% had no habits, 51% had multiple habits. The mean age of starting tobacco was 34 years (range: 8-66 years).

The mean duration of symptoms was seven months (range: 1-36 months).The patients commonly sought medical help for persistent ulcer or mass in the oral cavity (62%), pain (34%), or skin involvement. Majority (85%) observed these lesions themselves. Eighty-one percent patients had pain during the course of illness and only 48% had pain relief with analgesics.

Similar to that defined by previous authors, [4] we also defined delay in treatment as time more than three months taken for definitive treatment after the onset of the first symptoms. Although more than one cause existed for delay in receiving medical care, the most common cause of delay in this study was due to delayed presentation by the patients themselves (52%). A significant percentage of patients (50%) also reported delayed diagnosis by the primary care physician before referring them to a tertiary care center. Other causes included treatment by nonmedical personnel (18%), alternative or traditional treatments (16%), and poor financial status (14%). Lack of awareness was the commonest cause for patients not seeking medical advice at the proper time. A small percentage (4%) was in denial of disease or had fear of coming to the hospital.

To understand further, these delays were divided into primary, secondary, or tertiary. Primary delay was defined as time duration from onset of symptoms to seeking medical advice from the primary care physician. The patients themselves caused this delay. Secondary delay was the time duration from seeking medical advice to referral to a tertiary care center (our institute in this case). This was primarily due to the delay caused by the primary care physician. Tertiary delay was the time duration from seeking medical advice at our institution to the start of definitive treatment. Primary delay was the longest with a mean of 2.75 months followed by secondary delay of 1.94 months and a tertiary delay of 1.4 months.

» Discussion

Cancers of the oral cavity are common in India. Unfortunately, most of these patients present in advanced stages, making their treatment more complex, expensive, and prolonged with significant functional and cosmetic deformity. Large tumors commonly occur due to undue delay in receiving definitive treatment. While there is no consensus in the literature to define the exact time period of delay in receiving treatment, it ranges from 21 days to three months in various studies. The mean length of delay in receiving treatment as per the literature surveyed ranged from 1.7 to 5.6 months. [5],[6]

It is well recognized that survival rates are improved if the disease is treated in its early stage. As shown by a large population-based study, [3] oral visual screening can reduce mortality in high-risk individuals. Another case control study [4] showed a shift from advanced to early stages after the introduction of the program. Although screening and prevention of various cancers is an active part of the health-care system, there has been no significant effort in early detection of oral cancers.

Delay in seeking treatment by the patient is defined as the primary delay. Most often as reported in the literature, this is the commonest cause of delay. [7] It has been estimated that about 50% of the patients with oral cancer make a first visit to a health-care professional within 1-2 months of becoming aware of symptoms, whereas about 20-30% of the patients delay seeking help for more than three months. [8],[9],[10] In the present study, as mentioned previously, we observed a mean primary delay of approximately three months. Oral self-examination can be an effective way to identify abnormal oral lesions early. In fact 85% of the patients interviewed for our study had observed these lesions themselves. However, due to the lack of awareness and absence of pain to begin with, many of them ignored these before these lesions increased in size. Hence, the general population needs to be made aware of the common presentations of oral cancers through education, media, or medical camps. Twenty-six percent patients had primary education and 62% had regular employment. No significant correlation was observed between these and the primary delay.

Access to medical care is another important factor influencing patients seeking early medical care. In India, the primary health center is the initial node of the health-care delivery system. In the present study, the mean distance to the nearest health-care center was reported as 10 km. Although this is not a big distance by itself, in many parts of rural India, access by road is still not easy. In some places, public health-care facilities may not be functional and may be provided by alternative or traditional health-care practitioners. About 10% of the patients sought their help initially in the present study.

Despite being by a trained medical practitioner, a lot of patients had to spend a significant amount of time in getting the correct diagnosis. We defined this time as secondary delay in our study and it was approximately two months on an average. Lack of awareness among general practitioners could be one important reason for this delay. However, lack of other facilities like medicines, surgical instruments, paramedical staff, and trained pathologists could also deter a medical practitioner from getting a biopsy of these lesions quickly. An ulcer or mass in the oral cavity was the most common symptom prompting patients to seek medical advice. Hence, all chronic oral ulcers with or without pain must be evaluated and biopsied.

Patients did spend some time waiting before getting operated in the tertiary care center as well (tertiary delay). In this study, it was approximately 1.4 months. The most important cause of this delay was due to the long wait list in our center due to heavy patient turnover.

Occurr at a visible site and could be detected easily, many patients with oral cancers presented in advanced stages with large tumors. The average total duration from symptoms to treatment was months. The main reasons for this delay were due to the patients themselves (primary delay) or due to time taken by the primary physician to diagnose the condition (secondary delay). The majority of the lesions were observed by the patients themselves, indicating that oral self-examination have a role in the early detection of disease. However, a lack of awareness among patients as well as medical practitioners resulted in the undue delay in many cases.